Chimeric Antigen Receptor T Cells against CD19 for Multiple Myeloma Alfred L. Garfall, M.D., Marcela V. Maus, M.D., Ph.D., Wei ‑ Ting Hwang, Ph.D., Simon F. Lacey, Ph.D., Yolanda D. Mahnke, Ph.D., J. Joseph Melenhorst, Ph.D., Zhaohui Zheng, M.S., Dan T. Vogl, M.D., Adam D. Cohen, M.D., Brendan M. Weiss, M.D., Karen Dengel, R.N., B.S.N., Naseem D.S. Kerr, M.P.H., Adam Bagg, M.D., Bruce L. Levine, Ph.D., Carl H. June, M.D., and Edward A. Stadtmauer, M.D. The new england journal of medicine published on Sept 10, 2015, R1 이형우 / Prof. 한재준

INTRODUCTION Transduction of autologous T cells to express CD19-specific chimeric antigen receptors is a promising immunotherapeutic approach for the treatment of B-cell cancers. Multiple myeloma is a B-lineage cancer that is reported to express CD19 infrequently. –Minor component of the MM has a B-cell (CD19 positive) phenotype. –CTL019 cells are cytotoxic for cells with extremely low levels of CD19 expression CTL019 cells might be effective only in conjunction with a therapy that depletes CD19-negative plasma cells.

Case report Patients –F/43, IgA kappa multiple myeloma(2009), vertebral comp. Fx. –Initial response to Tx with LEN, BTZ and DEX –high-dose melphalan (200 mg/m2 ) & autologous stem-cell ransplantation ( ) –Disease progression → CTL019 cell infusion & 2 nd autologous transplantation ( )

METHODS Study Design –Disease progression within 1 year after the initial autologous transplantation –Adequate cardiopulmonary function –Cryopreserved autologous hematopoietic stem cells –CTL019 cells are manufactured from an autologous leukapheresis product –high-dose melphalan (140 to 200 mg/m2) → reinfusion of autologous stem cells → CTL019 infusion 12 to 14 days later. → maintenance therapy - lenalidomide,100 days after transplantation *Standard dose - melphalan (200 mg/m2)

RESULTS Feasibility and Toxic Effects The CTL019 dose was 5×107 chimeric antigen receptor–expressing T cells After CTL019 infusion, –No fevers, No other signs of the cytokine release syndrome –No an inflammatory reaction –No other adverse events, earlier were grade 1 or 2. Hypogammaglobulinemia –a common finding in Patient with MM –it persisted at day 100 after transplantation

RESULTS Clinical Response The monoclonal and total IgA concentration decline after transplantation and after CTL019 infusion On day 100, a BM Bx - 1 to 2% overall cellularity and no plasma cells “stringent complete response” Lenalidomide - 5 mg daily(On day 130) → 5 mg twice weekly

RESULTS 12 months after transplantation → No evidence of monoclonal immunoglobulin on serum and urine immunofixation → No clinical signs or symptoms of multiple myeloma Transplantation with CTL019 cells : more complete and more durable reduction in multiple myeloma burden comparing with the first transplantation and all other prior therapies.

CTL019 Engraftment, Systemic Inflammatory Markers, and B-Cell Aplasia CTL019 cells detected by flow cytometry and quantitative PCR –in the PB from day 2 until day 47 after infusion –in the BM on day 30 fter infusion → but NOT on day 88 after infusion (day 100 after transplantation) Reconstitution of B cells was associated with loss of detectable CTL019 Early B-cell aplasia ← the combined effects of CTL019 and melphalan RESULTS

CD19 Expression in Multiple Myeloma Cells Dominant population of neoplastic plasma cells –CD38+CD45− immunophenotype and kappa light chain –CD19 was detected on merely 0.05% ① The minor CD19+subset expressed intracellular kappa light chain ② kappa-restricted plasma cells CD45+,CD19+ ③ polyclonal CD19+ CD20+ B cells ④ pro-B or early pre-B cells CD45+CD38(dim)+CD20−CD19+ light-chain–negative cells → target of CTL019 ①

③ ② ④

CONCLUSION Advanced, refractory multiple myeloma in which a durable complete response has been attained with CTL019 infusion after treatment with high-dose melphalan and autologous transplantation